Cverv|ew of Commun|ty-

acqu|red neumon|a
8onald Crossman Mu
rofessor of Medlclne, unlverslLy of 1oronLo
CredlL valley PosplLal, Mlsslssauga, CnLarlo
Learn|ng Cb[ecnves
Aer Lhls sesslon, learners wlll be able Lo:
AppreclaLe Lhe relauve lmporLance of paLhogens ln
CA
SLraufy pauenLs accordlng Lo severlLy of lllness
8ecognlze Lhe lmpacL of currenL Lherapeuuc
recommendauons
undersLand lmprovemenLs ln processes of care
CAP: Incidence and Outcomes
8th leading cause of death in United States
2-3 million cases/year
500,000 admissions/year
> 60,000 deaths/year
Mortality
Outpatient < 1%
Admit (ward) 10%-14%
ICU 30%-40%
Bartlett JG et al. Clin Infect Dis. 2000;31:347-382
File TM, et al. Postgrad Med 2010; 122:130-41
0 3 10 13 20 23 30
5 poeomooloe
c poeomooloe*
vlral
M poeomooloe
leqlooello spp
n lofoeozoe
C-ve enLerobacLerla
c psluocl
coxlello botoeul
5 ooteos
M cotottbolls
CLher
Data from 26 prospective studies (5961 adults) from 10 countries.
*Data from 6 studies; Woodhead, Mass, 1998.
8acter|o|ogy of nosp|ta||zed CA
Percentage of Cases
Lp|dem|o|og|ca| Cond|nons and
ke|ated athogens |n CA
condinon common/y encountered pothoqen{s)
Alcohollsm 5. poeomooloe and anaerobes
CCu and/or smoklng 5. poeomooloe, n. lofoeozoe, M. cotottbolls, and
leqlooello specles
nurslng home resldency 5. poeomooloe, gram-negauve bacllll, n.
lofoeozoe, 5. ooteos, anaerobes, and c.
poeomooloe
oor denLal hyglene Anaerobes
Lpldemlc Leglonnalres' dlsease leqlooello specles
Lxposure Lo baLs or soll enrlched
wlLh blrd dropplngs
nlstoplosmo copsolotom
Lxposure Lo blrds cblomyJlo psluocl
Lxposure Lo rabblLs ltooclsello toloteosls
Bartlett JG, et al. Clin Infect Dis. 2000;31:347-82
Lno|ogy of CA: Ward anents
rospecuve sLudy of
3323 pLs ln 8arcelona
from 1996 - 2008
83 lnpauenLs
Luology deLermlned ln
42
5. poeomooloe ln 43
ALyplcals ln 16
(Leglonella 8)

S pneumo
P lnfl
ALyplcal
vlrus
S aureus
CnL8
seudo
Mlxed
Cillniz C, et al. Thorax 2011; 66:340-6
Lno|ogy of CA: ICU anents
8acLeremla ln 9, malnly
5. poeomooloe (80)
MorLallLy: 7
5 poeomooloe had Lhe
hlghesL number of deaLhs
whlle CnL8, l oetoqlooso,
5. ooteos and mlxed
euologles had Lhe hlghesL
morLallLy raLes

S pneumo
P lnfl
ALyplcal
vlrus
S aureus
CnL8
seudo
Mlxed
Cillniz C, et al. Thorax 2011; 66:340-6
SI1L CI CAkL DLCISICNS
App|y|ng the CUk8-6S ku|e
Score: 0 - 1, morLallLy
raLe <2
osslbly sulLed for
home managemenL
Score: 2, lnLermedlaLe
rlsk of deaLh (9)
Conslder for
hosplLal Lherapy
Score >2, hlgh morLallLy
raLe (>19)
Manage ln hosplLal
as severe CA
0 or 1 2 3 +
Any of:
Confusion*
Urea >7 mmol/l
Respiratory Rate 30/min
Blood pressure (SBP <90 mmHg or DBP 60 mm Hg)
Age 65 years
Group 1
Mortality
Low
(1.5%)
(n=324, died=5)
Group 2
Mortality
Intermediate (9.2%)
(n=184, died=17)
Group 3
Mortality
High
(22%)
(n=210, died=47)
Likely suitable for
home treatment
Consider hospital
supervised
treatment
Options may include:
Short stay inpatient;
Hospital-supervised
outpatient
Manage in hospital
as severe
pneumonia
Assess for ICU admission
especially if CURB-65
score = 4 or 5
CURB-65
Score
Treatment
Options
*Defined as a mental test score of 8 or less, or
new disorientation in person, place or time.
.
Llm WS eL al. 1horax. 2003, 38:377-82
neumon|a Ck1 red|cnon ku|e for
Morta||ty k|sk Assessment
STEP 1 STEP 2
No
No
Class I
No
Yes
Yes
Yes
Class III
(7190 points)
Class IV
(91130 points)
Class V
(>130 points)
Class II
(70 points)
Assign points for:
Demographic
variables
Comorbid conditions
Physical
observations
Laboratory and
radiographic findings
Is the patient >50 years of age?
Does the patient have any of the
following coexisting conditions:
Neoplastic disease; congestive heart
failure; cerebrovascular disease; renal
disease; liver disease
Does the patient have any of the
following abnormalities:
Altered mental status; pulse 125/min;
respiratory rate 30/min; systolic blood
pressure <90 mmHg; temperature
<35C or 40C
Fine MJ et al. N Engl J Med. 1997; 336:243-250.`
kounne Use of SI keduces nosp|ta|
Adm|ss|ons
prospecuve, observauonal,
conLrolled cohorL sLudy
8 lrench Lus LhaL used Sl
and 8 Lus LhaL dld noL
(n=923)
ln Sl-user Lus, 42.8 of low
rlsk pLs were LreaLed as
ouLpauenLs, cf. 23.9 of low
rlsk pLs ln Sl-nonuser Lus
Maln dlerence seen ln Sl
classes l and ll
0
10
20
30
40
50
60
70
80
I II III IV-V
PSI User Eds PSI Non-User Eds
% Patients Treated as Outpatients
Renaud B, et al. Clin Infect Dis 2007; 44:41-9
red|cnon of In-nosp|ta| Death due to
CA
Cbservauonal sLudy of
CAnL1Z neLwork
660,394 pauenLs were
lnvesugaLed
MorLallLy was n=93,938
(14.0)
C88-63 ls noL ldeal and ln
many pauenLs, evaluauon
of funcuonal sLaLus and
comorbldlLy lmproves
prognosucauon
0
1
2
3
4
3
Cdds 8auo for MorLallLy
Lwlg S, eL al. L8! 2013, 41:917-922
Mod|hed A1S]IDSA Cr|ter|a of
Sever|ty
1 of 2 ma[or parameLers
8equlremenL of mechanlcal venulauon
Sepuc shock
Mandell LA, et al. Clin Infect Dis 2007; 44: S27-72
Mod|hed A1S]IDSA Cr|ter|a of
Sever|ty
Any 3 of 9 basellne (mlnor) cllnlcal parameLers:
f 30 breaLhs/mln
Confuslon/dlsorlenLauon
uremla (8un 20 mg/dL)
Leukopenla (W8C < 4000 cells/mm
3
)
SysLollc bp < 90 mm Pg
Mululobar lnlLraLes
aC2/llC2 rauo < 230
1hrombocyLopenla (plaLeleLs < 100,000 cells/mm
3
)
PypoLhermla (core Lemp < 36C)
8 requlrlng aggresslve uld resusclLauon

Mandell LA, et al. Clin Infect Dis 2007; 44: S27-72
prospecuve observauonal
sLudy of 1062 consecuuve
adulL CA pLs
2 denluons of severe CA
were prlmary end polnLs:
lCu admlsslon
Mechanlcal venulauon (Mv) or
vasopressor supporL (vS)
luSA/A1S 2007 crlLerla
were as good as any scorlng
sysLem for predlcuon of
Mv/vS and lCu admlsslon
erformance of IDSA]A1S Sever|ty Cr|ter|a
Compared to Cther Sever|ty Measures
Chalmers JD et al. Clin Infect Dis. 2011; 53: 503-511
0.63 0.7 0.73 0.8 0.83 0.9
luSA/A1S
Sl
Cu8863
SMA81-CC
SCA
Mv/vS lCu AdmlL
AUC
WnA1 DC 8ICMAkkLkS ADD 1C
CLINICAL LVALUA1ICN?
8|omarkers - roca|c|ton|n (C1)
A calclLonln precursor LhaL ls elevaLed ln lnfecuon
as well as Lrauma, burns and neuroendocrlne
Lumors
used as a marker of bacLerlal vs. vlral lnfecuon
1o reduce durauon of anublouc Lherapy
especlally ln pLs wlLh mlld-Lo-moderaLe dlsease
Level ls relaLed Lo severlLy of dlsease
lmprovemenL of morLallLy predlcuon ls varlable
Nomogram for Annb|onc Usage
CAP Diagnosis
PCT Concentration
< 0.25 g/ml >0.25 - 0.5 g/ml
0.5 - <1 g/ml
1 g/ml
Antibiotics
discouraged
Antibiotics
encouraged
Antibiotics
strongly
encouraged
Antibiotics
strongly
discouraged
a time-resolved amplified cryptate emission technology assay
(Kryptor PCT; Brahms AG, Hennigsdorf, Germany)
Christ-Crain M, et al, AJRCCM 2006; 174:84-93
roca|c|ton|n-8ased Annb|onc
Gu|dance |n CA
8C1 ln 302 consecuuve pLs
wlLh suspecLed CA
ConLrol: (n=131) usual
anublouc pracuce
lnLervenuon: (n=131)
anublouc nomogram used
LoLal anublouc exposure
(88, 0.32, 93 Cl, 0.48-
0.33, p < 0.001)
anublouc durauon
(medlan, 3 vs. 12 d, p <
0.001)
Christ-Crain M, et al, AJRCCM 2006; 174:84-93
SchueLz eL al. Clln lnfecL uls. 2012, 33:631-662
Meta-Ana|ys|s of C1 to Gu|de Annb|onc In|nanon and
Duranon of Annb|onc 1herapy
rlmary
Care
Lu
lCu
u81l
CA
vA
8ronchlus
ALCCu
All
N1-pro8N Leve|s at resentanon |n
Short-term Surv|vors vs. Nonsurv|vors
Nowak A et al. Chest 2012;141:974-982
What Does |t A|| Mean?
rocalclLonln has been used Lo gulde anublouc
Lherapy (lnlual LreaLmenL and durauon of Lherapy)
noL an ldeal marker Lo dlscrlmlnaLe bacLerlal from
vlral lnfecuons
Can shorLen durauon of Lherapy lf long courses of
Lherapy are rouune
Conlcung resulLs abouL Lhe value of C1 Lo predlcL
ouLcomes compared Lo sLandard scorlng sysLems
Markers of cardlac sLress are promlslng and need
Lo be pursued
DCN'1 ICkGL1 C1nLk
8ICMAkkLkS
Impact of Adm|ss|on nypog|ycem|a on
Morta||ty |n CA
Lxamlned lmpacL of
admlsslon hypoglycemla
(<4.0 mmol/L [n=34]) or
normoglycemla (4.0
Lo<6.1 mmol/L [n=902])
on morLallLy
ln-hosplLal morLallLy
hlgher ([aP8] 2.96, 93
Cl, 1.39-6.31, l=.003)
8esulLs noL aecLed by
LreaLmenL for uM
0
3
10
13
20
23
30
33
ln-PosplLal
MorLallLy
30-uay
MorLallLy
1-?ear
MorLallLy
20 20
33
9 9
23
Pypoglycemla normoglycemla
Gamble J-M, et al. Am J Med 2010; 123:556e11-e16
%

M
o
r
t
a
l
i
t
y

ropens|ty-ad[usted k|sk of 30-day
Morta||ty by Adm|ss|on |ate|et and W8C
Count
Mirsaeidi M et al. Chest 2010;137:416-420
Retrosectlve cohort
study of cc consecutlve
hosltullzed CAP ts
Plutelet count wus
strongly ussocluted ( = .
ccc) wlth cduy
mortullty
No ussoclutlon wus
observed for leukocyte
count ( = .)
nypocapn|a and nypercapn|a Are
red|ctors for ICU Adm|ss|on and
Morta||ty
8eLrospecuve sLudy of 433 pLs
admlued wlLh CA
aCC2: ^30-day morLallLy (C8 =
2.84, 93 Cl, 1.28-6.30) and ^need
for lCu admlsslon (C8 = 2.88, 93 Cl,
1.68-4.93) compared wlLh pLs wlLh
normal aCC2
^ aCC2: ^30-day morLallLy (C8 =
3.38, 93 Cl, 1.38-8.30) and ^need
for lCu admlsslon (C8 = 3.33, 93 Cl,
2.80-10.23)

Laserna L, eL al. CPLS1. 2012,142(3):1193-1199
IS 1nL CnCICL CI INI1IAL LMIkIC
AN1IMICkC8IAL 1nLkA
IMCk1AN1?
Iactors Se|ected by Mu|nvar|ate Ana|ys|s
Independent|y ke|ated to Morta||ty
Variable Relative O.R. p Value
Underlying disease (UF
+ RF)
3.09 .0007
Shock 2.85 0.016
Bacteremia 2.63 0.019
Ineffective Initial
Therapy
4.71 .0001
Leroy O. Intensive Care Med 1995; 21:24-31

IS WnLN CU ADMINIS1Lk 1nL
AN1I8IC1IC IMCk1AN1?
Lect of Lar|y Adm|n|stranon of
Annb|oncs on Cutcomes
Variable All
patients
Antibiotics
within 4 hours
Antibiotics
after 4 hours
Adjusted
Odds Ratio
p
Value
30-day mortality 12.0 11.6 12.7 0.85 .005
In-hospital mortality 7.0 6.8 7.4 0.85 .03
% of patients with LOS>5
days
43.3 42.1 45.1 0.90 .003
30-day readmission rate 13.4 13.1 13.9 0.95 .34
Houck PM et al. Arch Intern Med 2004; 164:637-44
Un|ntended Consequences of the 4-h
Annb|onc ku|e
lollowlng lmplemenLauon of Lhe 4-hour rule:
recelved anubloucs wlLhln 4 h (63.8 vs. 33.3,
p=0.007)
had an adm|ss|on CA d|agnos|s w|thout Ckk
abnorma||nes (28.3 vs. 20.6, p=0.04)
8lood culLures (69.6 vs. 46.7, p<0.001)
I|na| d|agnos|s of CA (38.9 vs. 73.9, p<0.001)
Mean annb|onc un||zanon]panent (1.66 vs. 1.39,
p<0.001)
no dlerences ln Sl, Cu88-63 scores or morLallLy
Kanwar M, et al, Chest 2007; 131:1865-9
WnA1 IS 1nL kCLL ICk
CCM8INA1ICN 1nLkA VS. SINGLL
AGLN1 1nLkA IN 8AC1LkLMIC
NLUMCCCCCAL NLUMCNIA?
Comb|nanon 1herapy |n Severe CA
rospecuve, mulucenLer
observauonal sLudy of
844 adulLs wlLh
bacLeremla due Lo 5.
poeomooloe
Among crlucally lll
pauenLs, morLallLy
reduced: 23.4 vs.
33.3, l=0.00130
0.0
0.2
0.4
0.6
0.8
1.0
0 7 14 21 28 35
P
r
o
b
a
b
i
l
i
t
y

o
f

s
u
r
v
i
v
a
l

Days post blood culture
Combination therapy n=47
Monotherapy n=47
Baddour LM, et al. Am J Respir Crit Care Med. 2004;
170:440-44.
WnC GL1S SL1IC SnCCk IN
NLUMCCCCCAL NLUMCNIA?
Sepnc Shock |n neumococca|
neumon|a
rospecuve
observauonal sLudy of
1041 pLs wlLh
pneumococcal
pneumonla
10.9 had sepuc
shock aL admlsslon
Shock No Shock p
Va|ue
8acLeremla
()
41.2 29.7 .014
lCu AdmlL
()
48.2 6.9 <.001
Mv () 36.8 4.4 <.001

LCS (days) 11 8 <.001

MorLallLy () 23.4 3.2 <.001

Garcia-Vidal C, et al. Thorax 2010; 65:77-81
k|sk Iactors for Sepnc Shock |n
neumococca| neumon|a
0 0.3 1 1.3 2 2.3 3 3.3 4 4.3
CurrenL smoklng
Chronlc corLlcosLerold use
SeroLype 3
Mu|t|var|ate Ana|ys|s
Garcia-Vidal C, et al. Thorax 2010; 65:77-81
WnC GL1S LUNG NLCkCSIS WI1n
NLUMCCCCCAL INILC1ICN?
reva|ence of Common Serotypes
Pande A et al. Clin Infect Dis. 2012; 54:10-16
331 cases of pneumococcal
pneumonla
necrouzlng changes were
ldenued ln 23 of 331 (6.6)
pauenLs (C1 changes)
Cen overlooked on lnlual
readlngs
1ype 3 pneumococcus was
Lhe mosL commonly ldenued
seroLype
C||n|ca| ke|evance of Drug-kes|stant
5. pneumonioe |n CA
-lacLams
MlC of >4
2
nd
-generauon cephalosporlns
Macrolldes
number of cases conunues Lo grow
Low-level (mef) and hlgh-level (etm) reslsLance are relevanL
lluoroqulnolones
Small number of cases
!udlclous use
Yu VL, et al. Clin Infect Dis. 2003;37:230-237;
Feikin DR, et al. Am J Public Health. 2000;90:223-9.
reva|ence of kes|stance Among
neumococc|, by r|or Macro||de Use
0
10
20
30
40
50
60
No macrolide Erythro Clari Azithro
R
a
t
e

o
f

m
a
c
r
o
l
i
d
e

r
e
s
i
s
t
a
n
c
e

i
n

i
n
f
e
c
t
i
n
g

i
s
o
l
a
t
e
s

p=.02
p=.004
Vanderkooi OG, et al. Clin Infect Dis 2005; 40:1288-97
p<.001
Impact of en|c||||n kes|stance on
Morta||ty
10 studies involving 3430 pts
mortality rate:
19.4% in the PNSP group
15.7% in the PSSP group
RR of mortality for PNSSP vs. PSSP
was 1.29 (95% CI, 1.041.59) in 6
studies adjusted for age,
comorbidities, and severity of
illness
RR of mortality when Rx was
concordant or discordant was
identical (RR, 1.6)
Tleyjeh IM, et al. CID 2006;42:788-797
WnA1 DC GUIDLLINLS SA A8CU1
INI1IAL LMIkIC 1nLkA CI
NLUMCNIA?
2007 A1S]IDSA Gu|de||nes: Inpanents
Mandell LA, eL al. cllo lofect uls 2007, 44: S27-72
CAP Inpatient Therapy
Medical Ward
Recent
Antibiotic
No Recent
Antibiotic
Respiratory fluoroquinolone
alone
OR
Advanced macrolide
+
-lactam
Regimen selected will depend on nature of recent antibiotic
therapy (Moxi, Levo 750)
Advanced macrolide
+
-lactam
OR
respiratory
fluoroquinolone alone*
2007 A1S]IDSA Gu|de||nes: Inpanents
Mandell LA, eL al. cllo lofect uls 2007, 44: S27-72
Intensive Care Unit
No Pseudomonas
Risk
No -lactam
Allergy
-lactam
Allergy
-lactam
+
Either advanced
macrolide
OR
respiratory
fluoroquinolone
Regimen selected will depend on nature of recent
antibiotic therapy (Moxi, Levo 750)
Respiratory
fluoroquinolone
+
aztreonam
Pseudomonas Risk
No -lactam
Allergy
-lactam
Allergy
Anti-pseudomonal,
antipneumococcal b-lactam /
penem
+
Cipro/Levo 750
OR
Anti-pseudomonal,
antipneumococcal b-
lactam /penem
+
aminoglycoside
+
Azithromycin
Aztreonam
+
respiratory
fluoroquinolone
+
aminoglycoside

Impact of Macro||de 1herapy on Morta||ty for
anents w|th Severe Seps|s due to neumon|a
reLrospecuve cohorL sLudy of
787 CA pLs
30.1 had severe sepsls
Cf Lhose, 43.9 recelved
macrolldes
WlLh Mv analysls, 30-day
morLallLy (P8 0.3, 93 Cl 0.2-
0.7) and 90 days (P8 0.3, 93
Cl 0.2-0.6) ln pLs wlLh severe
sepsls and pLs wlLh
macrollde-reslsLanL
paLhogens (P8 0.1, 93 Cl 0.02-
0.3)
All pts
Culture ve sepsis
Culture +ve
sepsis
Macrolide-
resistant
severe sepsis`
Restrepo MI, et al. Eur Respir J 2009; 33: 153 - 159
Meta-Ana|ys|s of kC1S of Macro||de-based
keg|mens versus Non-macro||de 1herapy
and Morta||ty
Asadl L eL al. Clln lnfecL uls. 2012, 33:371-380
Adherence to Gu|de||nes and CA
Cutcome
rospecuve
observauonal sLudy of
780 pLs
morLallLy less ln pLs LhaL
recelved adherenL
reglmens (3 vetsos
10.6)
ShorLer lengLh of sLay ln
pLs recelvlng adherenL
reglmens (7.6 vetsos
10.4 days).
0 1 2 3 4 5 6 7 8
Adherence to ATS
guidelines
Obtundation
O2 sat < 90%
Acute renal failure
Shock
Aspiration
Odds Ratio for Mortality
Dambrava PG, et al, Eur Respir J 2008; 32:892-901

Lect of Corncostero|ds on CA
213 pLs were randomlzed Lo recelve
40 mg prednlsolone for 7 days or
placebo, along wlLh anubloucs
Luy Prednlsolone Plucebo
vulue
, 8c.8 8. c.8
c 66. ,,. c.c8
Snijders D, et al Am Rev Respir Crit Care Med
2010; 181:975-82
Clinical Cure
Commun|ty-acqu|red MkSA
severe, rapldly progresslve, oen necrouzlng pneumonla
frequenLly a hlsLory of precedlng lnuenza-llke lllness
frequenLly carry SCCmec alloLypes lv and v and also Lhe
lukSl-v genes, whlch encode anLon-valenune leukocldln
(vL), a leukoLoxln LhaL may be assoclaLed wlLh more severe
dlsease presenLauons
reslsLanL Lo all -lacLams lncludlng cephalosporlns,
cefamyclns and carbapenems
Francis JS, et al. Clin Infect Dis. 2005; 40: 100-7
Commun|ty-acqu|red MkSA
cyLoLoxln called anLon valenune leukocldln (vL):
assoclaLed wlLh prlmary skln lnfecuons and severe
necrouzlng pneumonla
creaLes lyuc pores ln Lhe cell membranes of MnLs
lnduces release of MnL chemoLacuc facLors
for Loxln-produclng sLralns, anubloucs LhaL lnhlblL proLeln
synLhesls (llnezolld or cllndamycln) may be beuer
concern of lnduclble cllndamycln reslsLance has dlscouraged
lLs use among cllnlclans
vancomycln does noL lnhlblL Lhe producuon of Lhe Loxlc vL
cyLoLoxln
Micek ST et al. Chest 2005; 128:2732-8
Probability of Survival of Patients with
Staphylococcal Pneumonia, With or Without the
Panton-Valentine Leukocidin (PVL) Gene
Rubinstein E et al. Clin Infect Dis.
2008;46:S378-S385
2008 by the Infectious Diseases Society of America
reva|ence of Meth|c||||n-kes|stant
5tophy/ococcus oureus as an Lno|ogy of CA
rospecuve observauonal sLudy of adulLs
hosplLallzed wlLh CA from 12 unlverslLy-amllaLed
emergency deparLmenLs ln Lhe uS
Among 627 pauenLs a paLhogen was ldenued ln 102
(17)
M8SA was ldenued ln 14 (2.4) pauenLs and ln 3
of pauenLs admlued Lo Lhe lCu
Moran C!, eL al. Clu 2012,34(8):1126-33
1reatment of CA-MkSA
lor severe communlLy M8SA lnfecuon, vancomycln remalns
Lhe LreaLmenL of cholce
A communlLy M8SA prevalence Lhreshold as low as 3-10
may be approprlaLe for use of emplrlcal vancomycln Lherapy
ln severe, llfe-LhreaLenlng lnfecuons
Some auLhorlues have recommended Lhe admlnlsLrauon of
an exoLoxln-reduclng agenL (llnezolld, cllndamycln, rlfamplcln,
fusldlc acld) for severe M8SA lnfecuons for whlch lukSl-v ls
deLecLed (eg, necrouzlng pneumonla)
Lhere are no daLa Lo supporL Lhe use of vancomycln ln
comblnauon wlLh Lhese anubloucs
Chua k, eL al. Clln lnfecL uls 2011,
32:99-114
AkL 1nLkL kCCLSSLS CI CAkL
1nA1 CAN SnCk1LN nCSI1AL
S1A AND IMkCVL CU1CCMLS?
1|me to C||n|ca| Stab|||ty
0
1
2
3
4
5
S
B
P
>
9
0
H
R
<
1
0
0
F
<
2
4
T
<
3
8
.
3
O
2

s
a
t
>
9
0
A
b
i
l
i
t
y

t
o

e
a
t
M
e
n
t
a
l

s
t
a
t
u
s
Days
Halm EA, et al JAMA 1998; 279:1452-7
rospecuve observauonal
sLudy of 668 pLs
Medlan ume Lo cllnlcal
sLablllLy was 2 -3 days
Aer reachlng cllnlcal sLablllLy,
cllnlcal deLerlorauon occurred
ln < 1 of cases
8eLween 63 - 86 of pLs
sLayed ln hosplLal > 1 day aer
reachlng sLablllLy
Lect of Lar|y Mob|||zanon on LCS |n
CA
8C1 of 438 pLs admlued Lo 17
CM unlLs
LM: slmng ouL of bed or
ambulaung for aL leasL 20 mln
durlng Lhe rsL 24 h of
hosplLallzauon
rogresslve moblllzauon
occurred each subsequenL day
durlng hosplLallzauon
1.1 (0.0-2.2) fewer days of
hosplLallzauon
no dlerence ln adverse evenLs
0
2
4
6
8
10
Usual Care Early
Mobilization
Days
Mundy L, et al, Chest 2003; 124:883-9
Lect of a 3 Step Cr|nca| athway on
LCS
8C1 of 401 CA pLs
Asslgned Lo crlucal paLhway or
usual care
Crlucal paLhway:
early moblllzauon of pauenLs
use of ob[ecuve crlLerla for
swlLchlng Lo oral anublouc
Lherapy
use of predened crlLerla for
decldlng on hosplLal dlscharge
0
1
2
3
4
3
6
7
8
9
10
Crlucal
aLhway
usual Care
p<.001
p<.001
p=ns
p=ns
Carratal J et al. Arch Intern Med 2012;():1-7. doi:
10.1001/archinternmed.2012.1690
Impact of CA nosp|ta||zanon on
Long-1erm Cutcome
8eLrospecuve, observauonal sLudy
of 2 groups ln one medlcal cenLer
Ls hosplLallzed wlLh CA [CA(+)]
compared Lo pLs hosplLallzed for
condluons oLher Lhan CA [CA(-)]
SlgnlcanLly shorLer survlval among
CA(+) pLs Lhan CA(-) pLs,
(p<0.0001)
novel ad[usLmenLs for preexlsung
comorbldlues Lhrough a
comorbldlLy lndex based on cllnlcal
daLa and age were made
Bordon J, et al, Chest; 2010; 138:279-283

anent w|th Lk1I |n LD
PlsLory
hyslcal examlnauon
ChesL radlograph
8ouune labs: C8C, lyLes, urea, Cr, glucose
C2 saL
Diagnosis: CAP
anent w|th Lk1I |n LD
use a severlLy assessmenL: Cu88-63/Sl
8lomarker: C8, C1, cardlac blomarker
Admlsslon/slLe-of-care declslon
anent w|th Lk1I |n LD
8lood culLures, urlne sLudles for leqlooello, 5.
poeomooloe, blood C8 for pneumococcus lf a
valldaLed lnsLrumenL ls avallable
SpuLum C8 for vlral, aLyplcal, bacLerlal paLhogens lf
valldaLed polnL-of-care lnsLrumenLs are avallable
Appllcauon of local slLe-of-care guldellne-dlrecLed
anublouc Lherapy modled by lnformauon gleaned
from dlagnosuc sLudles
SLarL Lherapy as soon as Lhe dlagnosls of CA ls
esLabllshed

anent w|th Lk1I
Asslgn a case manager lf avallable
uevelop care maps LhaL assure early moblllzauon
and early-swlLch Lherapy
use blomarkers Lo declde when lL ls safe Lo sLop
anublouc Lherapy
MonlLor for compllcauons (especlally cardlac)
ulscharge when cllnlcally sLable and able Lo LoleraLe
oral medlcauon and Lhe home supporLs are ln place
Arrange careful follow-up especlally lf blomarkers
conunue Lo be abnormal
8ouom L|ne
5. poeomooloe ls Lhe mosL lmporLanL paLhogen ln
Lhe euology of CA
Several Lools help ldenufy pauenLs LhaL requlre
hosplLal/lCu admlsslon
8lomarkers can help declde Lhe need and durauon
of anublouc Lherapy
8ouom L|ne
8acLerlal reslsLance ls prevalenL, and local raLes of
reslsLance should be consldered when selecung
anumlcroblal Lherapy
use of guldellnes lmprove ouLcomes
1here are lmproved processes of care LhaL can
shorLen hosplLal lengLh of sLay
1he dlagnosls of CA aecLs long Lerm ouLcome